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INTRODUCTION

Medical professionalism is defined as “a set of values, behaviors, and relationships that underpins the trust the public has in doctors.”1 Traditionally, doctors have committed themselves to the primary consideration of patient health and well-being.2 Therefore, ‘classical professionalism’ emphasizes altruism, considering patients' interests over those of doctors, and compassion, being willing to help patients in suffering or distress. Some people think the medical issues that cause social harm can be mainly attributed to an absence of professionalism and therefore, that establishing professionalism can help prevent such problems and restore social trust in professionals.1

However, there is a negative aspect to emphasizing classical professionalism because the medical environment has changed drastically in the last few decades. Medicine has become a big market for patients, doctors, pharmaceutical and insurance companies, the government, etc., and the scope of medicine is expending. The therapeutic patient-doctor relationship is no longer limited to visits by doctors with a medical bag. Most patient-doctor interactions now occur at hospitals equipped with various intervention devices. Pharmaceutical and medical device companies have become medical care suppliers, and hospitals have virtually become for-profit institutions. Patients seek the help of doctors to attain healthier and more beautiful bodies as well as to treat diseases. Medical care is strongly influenced by neoliberalism. These changes in the era of neoliberalism have fostered doubts about classical professionalism in medical care.3

This article discusses the requirements for feasible professionalism within the neoliberal medical environment in Korean society. This topic is meaningful because Korea has prominent neoliberal characteristics both in the medical field and in society, and it also has a different system from Western countries, where professionalism is actively discussed.

NEOLIBERALISM IN THE KOREAN HEALTH CARE SYSTEM

Since the introduction of Western medicine in Korea, private capital has been the main source of funding for setting up healthcare institutions. As a result, only 5.7% of hospitals that treat inpatients were public institutions in 2017.4 Most hospitals built with private capital seek profit and compete with each other. Many doctors are in managerial positions and want to recover

J Korean Med Sci. 2019 May 13;34(18):e125https://doi.org/10.3346/jkms.2019.34.e125eISSN 1598-6357·pISSN 1011-8934

Opinion

Received: Mar 11, 2019Accepted: Apr 3, 2019

Address for Correspondence: Do-Kyong Kim, MDDepartment of Medical Humanities, Dong-A University College of Medicine, 32 Daesingongwon-ro, Seo-gu, Busan 49201, Korea.E-mail: dinkum11@dau.ac.kr

© 2019 The Korean Academy of Medical Sciences.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ORCID iDsDo-Kyong Kim https://orcid.org/0000-0001-8639-1951

FundingThis work was supported by the Dong-A University research fund.

DisclosureThe author has no potential conflicts of interest to disclose.

Do-Kyong Kim

Department of Medical Humanities, Dong-A University College of Medicine, Busan, Korea

Medical Professionalism in Neoliberalism

Medicine General & Policy

their investments and run the hospital profitably, and even hired doctors are under pressure to make money for the hospital. As a result of competition, Korea has world-class medical services. However, as more patients, tests and treatments are linked to hospital revenues, doctors are more easily exposed to conflicts of interest and are more likely to over-intervene.

Unlike hospital establishments, reimbursements for medical services that are sources of income are made through public funds under the National Health Insurance Service (NHIS). It is mandatory for Koreans to join the NHIS, and many of them also have private insurance so that they can use medical services at a low cost. Hospitals compete to attract more patients, and patients are able to access medical services with few restrictions. A market structure in which doctors can gain economic benefits by providing more patients with more medical interventions and patients can use various medical services at low cost can lead to increased medical demand.

Neoliberalism encourages medical demand in the context of an individual's body as well as in the medical environment. Neoliberalism requires individuals to be competitive and differentiated through continuous self-development, and the body is no exception. Society presents an image of the ideal body and treats people as unable to manage themselves if they do not attain this image.5 This social atmosphere has led to efforts to achieve an ideal healthy and beautiful body in the realm of medicine.

In the context of neoliberal healthcare, some doctors add modifiers such as erosion, threats and crises to professionalism questioning values such as altruism and compassion.6-8 In Korea, where doctors have to make profits while competing with other hospitals, the altruistic attitude of “the patients' interests above all else” can bring about moral confusion even among doctors who want to provide their patients with the best care. Altruism and compassion are mainly inspired by the vulnerability of others, which imposes a moral obligation on those who care for vulnerable people. The vulnerability of patients suffering from illnesses has led to the commitment of doctors. However, it is questionable whether physicians who treat patients visiting hospitals to gain the ideal body have the same obligation.

Doctors have an obligation to provide patients with safe and profitable care and to distribute medical resources fairly. Professionalism is the collective actions that doctors are required to take in their roles.9 Professionalism should reflect the changing conditions of the times. Otherwise, it will only elevate the skeptical attitude of doctors towards professionalism as a simple symbolic slogan. Professionalism should be feasible.

TWO FACTORS FOR FEASIBLE PROFESSIONALISM IN NEOLIBERALISMFirst, it is necessary to embrace various values including commercialism, a hallmark of neoliberalism, when discussing professionalism. Those who think that a doctor's altruism and compassion are important and that commercialism threatens them will try to exclude commercialism from professionalism. On the other hand, those who consider classical professionalism to be no longer realistic may reject professionalism itself. Neither approach is appropriate. Since the influence of commercialism in healthcare will continue to grow, doctors should consider how they can play a professional role in this environment. Castellani and Hafferty10 suggested seven clusters of medical professionalism. They placed ‘entrepreneurial

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Creating Feasible Professionalism in Korea

professionalism’ as one of seven clusters and described commercialism as one of the systems that could influence professionalism. Compared to classical professionalism, entrepreneurial professionalism emphasizes commercialism, autonomy, and technical competence, and it de-emphasizes altruism, social justice, and the social contract.

Commercialism under the influence of professionalism recognizes that doctors seek economic benefits within social contracts, but it can draw a line against undue benefit from over-intervention or inadequate treatment. Society gives doctors a therapeutic privilege, and it demands that doctors do their best for their patients in the therapeutic relationship as well as to benefit society. Doctors with therapeutic privilege have to deliberate on competition between hospitals and the problems of creating medical demand as long as they do not hurt the social contract.

Second, feasible professionalism requires improvements to the environment to encourage respect for professional values. In other words, the system should be improved such that virtuous doctors do not experience moral conflicts caused by an unethical or unreasonable system. Some systems require excessive personal sacrifice for doctors to provide treatments that maximize patient benefits and require excessive courage to make fair distribution.

Korean doctors perform excessive work, not only for economic reasons, but also because human resources can redeem systemic defects. In such environments, doctors experience physical and mental exhaustion, and patient safety is threatened. System improvements go beyond individual dimensions. Hospitals and doctors' associations have to pay attention to the medical environment and improve the system.11 Also, they need to engage to improve healthcare policy reasonably. This effort will help create an environment that keeps social contracts as long as doctors are faithful to their work.

CONCLUSION

In neoliberalism, Korean doctors should persistently ask and ponder certain questions; namely, what role doctors play in Korean society, what patients and society demand, how to interpret altruism and compassion in the current climate, and how professionalism and commercialism can achieve harmony. Hospitals and doctors' associations should also try to create a system in which professionalism is respected and can flourish. Once this is achieved, we can expect the recovery of professional social trust.

REFERENCES

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2. World Medical Association (FR). WMA declaration of Geneva. https://www.wma.net/policies-post/wma-declaration-of-geneva. Updated 2018. Accessed March 27, 2019.

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4. Korean Statistical Information Service. Proportion of public medical institutions by province. http://kosis.kr/statHtml/statHtml.do?orgId=411&tblId=DT_411002_03&vw_cd=MT_ZTITLE&list_id=D1_411_002&seqNo=&lang_mode=ko&language=kor&obj_var_id=&itm_id=&conn_path=MT_ZTITLE. Undated 2019. Accessed January 29, 2019.

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9. George D, Gosenhauser I, Whitehouse P. Medical professionalism: the nature of story and the story of nature. In: Wear D, Aultman JM, editor. Professionalism in Medicine Critical Perspectives. New York (NY): Springer; 2006, 63-86.

10. Castellani B, Hafferty FW. The complexities of medical professionalism: a preliminary investigation. In: Wear D, Aultman JM, editor. Professionalism in Medicine Critical Perspectives. New York (NY): Springer; 2006, 3-23.

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